Basic Information
| Provider Information | |||||||||
| NPI: | 1144231044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METRO CHICAGO CARDIOTHORACIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 PARK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605632688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307180200 | ||||||||
| FaxNumber: | 6307180900 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122067467 | ||||||||
| FaxNumber: | 6308605262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | REKKAS | ||||||||
| AuthorizedOfficialFirstName: | DEEMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6307180200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 01636013 | 01 | IL | BLUE CROSS / BLUE SHIELD | OTHER |